Continue NCCN Clinical Practice Guidelines in Oncology™ Prevention and Treatment of Cancer- Related Infections V.2.2009 www.nccn.org Practice Guidelines in Oncology – v.2.2009 Prevention and Treatment of Cancer-Related Infections Version 2.2009, © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.08/28/09 Guidelines Index Prevention/Treatment Infection TOC Discussion, References NCCN ® NCCN Prevention and Treatment of Cancer-Related Infections Panel Members Brahm H. Segal, MD/Co-Chair Roswell Park Cancer Institute Lindsey Robert Baden, MD/Co-Chair Dana-Farber/Brigham and Women's Cancer Center | Massachusetts General Hospital Cancer Center Corey Casper, MD, MPH Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance Erik Dubberke, MD Siteman Cancer Center at Barnes- Jewish Hospital and Washington University School of Medicine Alison G. Freifeld, MD UNMC Eppley Cancer Center at The Nebraska Medical Center Michael Gelfand, MD St. Jude Children's Research Hospital/University of Tennessee Cancer Institute John N. Greene, MD H. Lee Moffitt Cancer Center & Research Institute F F F F F F F Þ Þ Guido Marcucci, MD Arthur G. James Cancer Hospital & Richard J. Solove Research Institute at The Ohio State University Kieren A. Marr, MD The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Jose G. Montoya, MD Stanford Comprehensive Cancer Center Ashley Morris-Engemann, PharmD Duke Comprehensive Cancer Center Peter G. Pappas, MD University of Alabama at Birmingham Comprehensive Cancer Center Ken Rolston, MD The University of Texas M.D. Anderson Cancer Center Susan K. Seo, MD Memorial Sloan-Kettering Cancer Center Þ † F F F å Þ F X å Infectious diseases ‡ Hematology/Hematology oncology Þ Internal medicine Pulmonary medicine † Medical oncology Pharmacology * Writing committee member Continue John P. Greer, MD Vanderbilt-Ingram Cancer Center Michael G. Ison, MD, MS Robert H. Lurie Comprehensive Cancer Center at Northwestern University James I. Ito, MD City of Hope Judith E. Karp, MD The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Daniel R. Kaul, MD University of Michigan Comprehensive Cancer Center Earl King, MD Fox Chase Cancer Center Emily Mackler, PharmD University of Michigan Comprehensive Cancer Center ‡ F F F X å ‡Þ * * Not for Distribution Practice Guidelines in Oncology – v.2.2009 Prevention and Treatment of Cancer-Related Infections Version 2.2009, © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.08/28/09 Guidelines Index Prevention/Treatment Infection TOC Discussion, References NCCN ® Table of Contents Site Specific Evaluation and Therapy: Panel Members Summary of Guideline Updates Antimicrobial Prophylaxis (INF-1) Antibacterial Prophylaxis (INF-2) Antifungal Prophylaxis (INF-3) Antiviral Prophylaxis (INF-4) Antipneumocystis Prophylaxis (INF-5) Prevention of Cytomegalovirus Disease (INF-6) Fever and Neutropenia (FEV-1) Initial Therapy (FEV-2) Initial Risk Assessment for Febrile Neutropenic Patients (FEV-3) Mouth, Esophagus, and Sinus/Nasal (FEV-4) Abdominal Pain, Perirectal Pain, Diarrhea, Vascular Access Devices (FEV-5) Lung Infiltrates (FEV-6) Cellulitis, Wound, Vesicular Lesions, Disseminated Papules or Other Lesions, Urinary Tract Symptoms, Central Nervous System Symptoms (FEV-7) · · · · These guidelines are a statement of consensus of the authors regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult these guidelines is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient's care or treatment. The National Comprehensive Cancer Network makes no representations or warranties of any kind whatsoever regarding their content, use, or application and disclaims any responsibility for their application or use in any way. These guidelines are copyrighted by National Comprehensive Cancer Network. All rights reserved. These guidelines and the illustrations herein may not be reproduced in any form without the express written permission of NCCN. © 2009. Clinical Trials: Categories of Evidence and Consensus: NCCN The believes that the best management for any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. To find clinical trials online at NCCN member institutions, All recommendations are Category 2A unless otherwise specified. See NCCN click here: nccn.org/clinical_trials/physician.html NCCN Categories of Evidence and Consensus Principles of Daily Follow-Up (FEV-8) Follow-Up Therapy for Responding Patients (FEV-9) Follow-Up Therapy for Nonresponding Patients (FEV-12) Outpatient Therapy for Low Risk Patients (FEV-13) Antibacterial Agents Table (FEV-A) Antifungal Agents Table (FEV-B) Antiviral Agents Table (FEV-C) Appropriate Use of Vancomycin (FEV-D) Risk Assessment Resources (FEV-E) Adjunctive Therapies (FEV-F) Guidelines Index Print the Prevention and Treatment of Cancer-Related Infections Guideline For help using these documents, please click here Discussion References Not for Distribution Practice Guidelines in Oncology – v.2.2009 Prevention and Treatment of Cancer-Related Infections Version 2.2009, © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.08/28/09 Guidelines Index Prevention/Treatment Infection TOC Discussion, References NCCN ® Summary of the Guidelines Updates Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. UPDATES INF-1 INF-3 INF-4 FEV-2 · · · · · · · Added clofarabine and nelarabine to the intermediate overall risk of infection in cancer patients category. Added “Purine analogs, intermediate risk when used as single agents, when combined with intensive chemotherapy regimens the risk converts to high.” Footnote a is new to the page: “Categories of risk are based on several factors, including underlying malignancy, whether disease is in remission, duration of neutropenia, prior exposure to chemotherapy, and intensity of immunosuppressive therapy.” Footnote b is new to the page: “Multiple immune deficits can co- exist in the same patient.” Itraconazole recommendation as prophylaxis changed from a category 1 to a category 2B level of evidence and consensus. Bortezomib was added as a therapy with high risk for varicella zoster reactivation for which antiviral prophylaxis should be considered. Footnote e was revised and now states: “Meta-analysis reported increased mortality associated with cefepime in randomized trials of neutropenic fever. However the FDA has concluded that cefepime remains appropriate therapy for its approved indications based on the results of the FDA’s recent meta-analysis.” (See Discussion) Summary of the changes in the 1.2009 version of the uidelines from the 1.2008 version include:Prevention and Treatment of Cancer-Related Infections G FEV-4 FEV-5 FEV-6 FEV-10 FEV-A (page 2 of 4) FEV-C (page 3 of 4) Following Mouth/mucosal initial clinical presentation, added “Consider leukemic infiltrate” to the evaluation. Following diarrhea added: “IV metronidazole should be used in patient who cannot take oral agents.” Footnote t is new to the page: “Rapid immunofluorescent viral antigen tests may be negative for H1N1 (swine flu).” Footnote u is new to the page: “Antiviral susceptibility of influenza strains is variable and cannot be predicted based on prior influenza outbreaks. In cases of seasonal influenza and pandemic strains (eg H1N1), it is necessary to be familiar with susceptibility patterns and guidelines on appropriate antiviral treatment.” Added Influenza: Oseltamivir is approved by FDA for 5 d based on data from ambulatory otherwise healthy individuals with intact immune systems; longer courses (ie, at least 10 d) and until resolution of symptoms should be considered in the highly immunocompromised. Added doripenim to the Antibacterial Agents Tables. Added tenofovir DF to the Antiviral Agents Tables. · · · · · Summary of the changes in the 2.2009 version of the uidelines from the 1.2009 version include: The addition of the updated Discussion section. Prevention and Treatment of Cancer-Related Infections G · Not for Distribution Practice Guidelines in Oncology – v.2.2009 Prevention and Treatment of Cancer-Related Infections Version 2.2009, © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.08/28/09 Guidelines Index Prevention/Treatment Infection TOC Discussion, References NCCN ® Low · · Standard chemotherapy regimens for most solid tumors Anticipated neutropenia less than 7 d Low · · · Bacterial - None Fungal - None Viral - None unless prior HSV episode Intermediate · · · · · · Autologous HSCT Lymphoma Multiple myeloma CLL Purine analog therapy (ie, fludarabine, clofarabine, nelarabine, 2-CdA) Anticipated neutropenia 7 to 10 d Usually HIGH, but some experts suggest modifications depending on patient status. Purine analogs, intermediate risk when used as single agents; when combined with intensive chemotherapy regimens, the risk converts to high. · · · Bacterial - Consider fluoroquinolone prophylaxis Fungal - Consider fluconazole during neutropenia and for anticipated mucositis Viral - During neutropenia and at least 30 d after HSCT High · · · · · Allogeneic HSCT Acute leukemia Induction Consolidation Alemtuzumab therapy GVHD treated with high dose steroids > > Anticipated neutropenia greater than 10 d · · · Bacterial - Consider fluoroquinolone prophylaxis Fungal - Viral - during neutropenia and at least 30 d after HSCT See INF-3 OVERALL INFECTION RISK IN CANCER PATIENTS a DISEASE / THERAPY EXAMPLES b FEVER & NEUTROPENIA RISK CATEGORY (See FEV-3) ANTIMICROBIAL PROPHYLAXIS c,d,e,f Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. a b c d Categories of risk are based on several factors, including underlying malignancy, whether disease is in remission, duration of neutropenia, prior exposure to chemotherapy, and intensity of immunosuppressive therapy. Multiple immune deficits can co-exist in the same patient. Pneumocystis prophylaxis . for dosing, spectrum, and specific comments/cautions. for dosing, spectrum, and specific comments/cautions. for dosing, spectrum, and specific comments/cautions. e f () ) See INF-5 See Antibacterial Agents (FEV-A See Antifungal Agents (FEV-B) See Antiviral Agents (FEV-C) KEY: 2-CdA = chlorodeoxyadenosine (cladribine), CLL = chronic lymphocytic leukemia, CMV = cytomegalovirus, GVHD = graft versus host disease, HSCT = hematopoietic stem cell transplant, HSV = herpes simplex virus, VZV = varicella zoster virus. Usually HIGH, but significant variability exists related to duration of neutropenia, immunosuppressive agents, and status of underlying malignancy INF-1 Not for Distribution Practice Guidelines in Oncology – v.2.2009 Prevention and Treatment of Cancer-Related Infections Version 2.2009, © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.08/28/09 Guidelines Index Prevention/Treatment Infection TOC Discussion, References NCCN ® OVERALL INFECTION RISK IN CANCER PATIENTS a Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. INF-2 Low Intermediate High DISEASE/THERAPY EXAMPLES AN BACTERIAL PROPHYLAXISTI d a g Categories of risk are based on several factors, including underlying malignancy, whether disease is in remission, duration of neutropenia, prior exposure to chemotherapy, and intensity of immunosuppressive therapy. Although data support levofloxacin prophylaxis for low- and intermediate-risk patients, the panel discourages this practice in low-risk patients (because of concerns about antimicrobial resistance); however, it can be considered in intermediate-risk patients. d for dosing, spectrum, and specific comments/cautions. See Antibacterial Agents (FEV-A) · · · · · · Autologous HSCT Anticipated neutropenia 7 to 10 d Lymphoma CLL Multiple myeloma Purine analog therapy None g Consider fluoroquinolone prophylaxis or None g Consider fluoroquinolone prophylaxis · · · Allogeneic HSCT (neutropenic) Acute leukemia (neutropenic) MDS (neutropenic) Anticipated neutropenia greater than 10 d· GVHD Penicillin and TMP/SMX DURATION · · Standard chemotherapy regimens for m solid tumors Anticipated neutropenia less than 7 d ost Alemtuzumab TMP/SMX For a minimum of 2 mo after alemtuzumab and until CD4 200 cells/mcL³ Not for Distribution Practice Guidelines in Oncology – v.2.2009 Prevention and Treatment of Cancer-Related Infections Version 2.2009, © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.08/28/09 Guidelines Index Prevention/Treatment Infection TOC Discussion, References NCCN ® INF-3 OVERALL INFECTION RISK IN CANCER PATIENTS a AN L PROPHYLAXISTIFUNGA e DURATION AML (neutropenic) h ALL h Autologous HSCT DISEASE/THERAPY EXAMPLES MDS (neutropenic) Allogeneic HSCT (neutropenic) Significant GVHD i · · Posaconazole (category 1) or k k Voriconazole (category 2B) or Amphotericin B products (category 2B) · l · · Fluconazole k or Amphotericin B products (category 2B) l · · Fluconazole (category 1) or Micafungin (category1) k With mucositis j Without mucositis Consider no prophylaxis (category 2B) Consider one of the following: Fluconazole (category 1) Micafungin (category 1) Voriconazole (category 2B) Posaconazole (category 2B) · · · · · k k k k Itraconazole (category 2B) · Amphotericin B products (category 2B) l Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Continue during neutropenia and for at least 75 d after transplant Until resolution of neutropenia a e k l Categories of risk are based on several factors, including underlying malignancy, whether disease is in remission, duration of neutropenia, prior exposure to chemotherapy, and intensity of immunosuppressive therapy. for dosing, spectrum, and specific comments/cautions. Recommendations on antifungal prophylaxis in patients with acute leukemia apply to those receiving induction or re-induction chemotherapy. Consider antifungal prophylaxis in all patients with GVHD receiving immunosuppressive therapy. See Antifungal Prophylaxis section of the Discussion. Severe mucositis is a risk factor for candidemia in patients with hematologic malignancies and stem cell transplant recipients not receiving antifungal prophylaxis. AItraconazole, voriconazole, and posaconazole are more potent inhibitors of hepatic cytochrome P450 3 4 isoenzymes than fluconazole and may significantly decrease the clearance of vinca alkaloids. A lipid formulation is generally preferred based on less toxicity. h i j See Antifungal Agents (FEV-B) Consider one of the following: Posaconazole (category 1)· · · k k Voriconazole (category 2B) Echinocandin (category 2B) )· Amphotericin B products (category 2B l Intermediate to High Until resolution of significant GVHD Not for Distribution Practice Guidelines in Oncology – v.2.2009 Prevention and Treatment of Cancer-Related Infections Version 2.2009, © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.08/28/09 Guidelines Index Prevention/Treatment Infection TOC Discussion, References NCCN ® Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. INF-4 a f Categories of risk are based on several factors, including underlying malignancy, whether disease is in remission, duration of neutropenia, prior exposure to chemotherapy, and intensity of immunosuppressive therapy. dosing,for spectrum, and specific comments/cautions. Among allogeneic HSCT, there is more experience with acyclovir and valacyclovir than famciclovir. Agents used as HSV prophylaxis are also active against VZV ( ). m n See Antiviral Agents (FEV-C See FEV-C ) KEY: 2-CdA = chlorodeoxyadenosine (cladribine), CLL = chronic lymphocytic leukemia, CMV = cytomegalovirus, GVHD = graft versus host disease, HSCT = hematopoietic stem cell transplant, HSV = herpes simplex virus, VZV = varicella zoster virus. OVERALL INFECTION RISK IN CANCER PATIENTS a DISEASE / THERAPY EXAMPLES HERPES VIRUSES ANTIVIRAL PROPHYLAXIS DURATION OF ANTIVIRAL PROPHYLAXIS f Intermediate · · · · · Autologous HSCT Lymphoma Multiple Myeloma CLL Purine analog therapy (ie, fludarabine) Low · Standard chemotherapy regimens for solid tumors · Acute leukemia Induction Consolidation > > High HSV HSV VZV HSV None unless prior HSV episode Acyclovir Famciclovir Valacyclovir Acyclovir Famciclovir Valacyclovir During neutropenia and at least 30 d after HSCT During neutropenia HSV VZV · Alemtuzumab therapy Allogeneic HSCT· Acyclovir Famciclovir or Valacyclovir as HSV prophylaxis m n HSV prophylaxis Minimum of 2 mo after alemtuzumab and until CD4 200 cells/mcL During neutropenia n · ³ · and at least 30 d after HSCT Pre-emptive therapy for CMV ( ) See INF-6 During neutropenia CMV (See INF-6) for CMV Bortezomib VZV Acyclovir Famciclovir Valacyclovir Not for Distribution Practice Guidelines in Oncology – v.2.2009 Prevention and Treatment of Cancer-Related Infections Version 2.2009, © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.08/28/09 Guidelines Index Prevention/Treatment Infection TOC Discussion, References NCCN ® INFECTION RISK IN CANCER PATIENTS a DISEASE / THERAPY EXAMPLES AN PROPHYLAXIS TIPNEUMOCYSTIS d Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. INF-5 High risk for Pneumocystis jirovecii (Pneumocystis carinii) Allogeneic stem cell recipients (category 1) Acute lymphocytic leukemia (category 1) Consider (category 2B): · Recipients of fludarabine and other T-cell depleting agents · Patients with neoplastic disease receiving prolonged corticosteroids or receiving temozolomide + radiation therapy o p · Autologous peripheral blood stem cell transplant recipients DURATION OF PROPHYLAXIS TMP/SMX (preferred) or Dapsone, aerosolized pentamidine, or aif TMP/SMX intolerant tovaquone q q For at least 180 d Throughout anti-leukemic therapy Until CD4 count is greater than 200 cells/mcL For a minimum of 2 mo after alemtuzumab and until CD4 200 cells/mcL³ Alemtuzumab 3-6 mo after transplant a p q Categories of risk are based on several factors, including underlying malignancy, whether disease is in remission, duration of neutropenia, prior exposure to chemotherapy, and intensity of immunosuppressive therapy. for dosing, spectrum, and specific comments/cautions. Risk of PCP is related to the daily dose and duration of corticosteroid therapy. Prophylaxis against PCP can be considered in patients receiving the prednisone equivalent of 20 mg or more daily for 4 or more weeks. atovaquone d o PCP prophylaxis should be used when temozolomide is administered concomitantly with radiation therapy and should be continued until recovery from lymphocytopenia. Consider trimethoprim/sulfamethoxazole desensitization or dapsone, aerosolized pentamidine, or when pneumonia prophylaxis is required, and patients are trimethoprim/sulfamethoxazole intolerant. Pneumocystis jirovecii See Antibacterial Agents (FEV-A) Not for Distribution Practice Guidelines in Oncology – v.2.2009 Prevention and Treatment of Cancer-Related Infections Version 2.2009, © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.08/28/09 Guidelines Index Prevention/Treatment Infection TOC Discussion, References NCCN ® Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. INF-6 PREVENTION OF CYTOMEGALOVIRUS DISEASE INFECTION RISK IN CANCER PATIENTS a DISEASE / THERAPY EXAMPLES SURVEILLANCE PERIOD r High risk for Cytomegalovirus disease Allogeneic stem cell transplant recipients Alemtuzumab · · · 1 to 6 months after transplant GVHD CD4 < 100 cells/mcL For a minimum of 2 mo after alemtuzumab and until CD4 100 cells/mcL³ PRE-EMPTIVE THERAPY f,s Ganciclovir (IV) or Foscarnet (IV) or Valganciclovir (PO) a f s Categories of risk are based on several factors, including underlying malignancy, whether disease is in remission, duration of neutropenia, prior exposure to chemotherapy, and intensity of immunosuppressive therapy. for dosing, spectrum, and specific comments/cautions. CMV surveillance consists of at least weekly monitoring of CMV by PCR or antigen testing. Duration of prophylaxis antiviral therapy generally is for at least 2 weeks and until CMV is no longer detected. r See Antiviral Agents (FEV-C) Not for Distribution [...]... filamentous fungal infections (IFFI): a randomized, prospective trial of a high loading regimen vs standard dosing (AmBiload Trial) Clin Infect Dis 2007;44:1289-97 7 Mora-Duarte J, Betts R, Rotstein C, et al Comparison of caspofungin and amphotericin B for invasive candidiasis N Engl J Med 2002;347:2020-9 8 Maertens J, Raad I, Petrikkos G, et al Efficacy and safety of caspofungin for treatment of invasive... f Documented infection Guidelines Index Prevention/ Treatment Infection TOC Discussion, References SUGGESTED DURATION OF THERAPY Fever of unknown origin Unstable Prevention and Treatment of Cancer-Related Infections rib ut io n NCCN ® timing to add empirical antifungal therapy varies with the risk of invasive mold infection but generally ranges between 4-7 d of neutropenic fever In patients at high... Candida In adults with normal renal · Active against dimorphic fungi (eg, function: 400 mg IV/PO histoplasmosis, coccidioidomycosis) daily and C neoformans Oral 400 mg daily (aim for · Active against Candida, Aspergillus species and some of the rarer molds trough of > 0.25 mcg/mL after 7 d of therapy) · Active against dimorphic fungi and C neoformans · Active against Candida, Aspergillus species and. .. Network, Inc All rights reserved These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN FEV-B (Page 2 of 4) NCCN ® Practice Guidelines in Oncology – v.2.2009 Prevention and Treatment of Cancer-Related Infections Guidelines Index Prevention/ Treatment Infection TOC Discussion, References ECHINOCANDINS d DOSE SPECTRUM · 70 mg IV x 1 dose, then... therapy for candidemia and invasive candidiasis · Superior efficacy compared to fluconazole as prophylaxis during neutropenia in HSCT recipients 11 · Excellent safety profile · Primary therapy for candidemia and invasive candidiasis (category 1) · Superior efficacy compared to fluconazole as primary therapy for candidemia and invasive candidiasis 12 · Excellent safety profile Continued on next page of centers... reserved These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN FEV-B (Page 3 of 4) NCCN ® Practice Guidelines in Oncology – v.2.2009 Prevention and Treatment of Cancer-Related Infections Guidelines Index Prevention/ Treatment Infection TOC Discussion, References rib ut io n REFERENCES FOR ANTIFUNGAL AGENTS (page 4 of 4) 1 Herbrecht N ot... clearance of less than 30 mL/min) · Uncontrolled/progressive cancer k · Pneumonia or other complex infections at clinical presentation · Alemtuzumab · Mucositis grade 3-4 OR · MASCC Risk Index score of less than 21 j or D is t Initial evaluation Guidelines Index Prevention/ Treatment Infection TOC Discussion, References Prevention and Treatment of Cancer-Related Infections rib ut io n NCCN ® TREATMENT. .. reserved These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN FEV-C (Page 1 of 4) NCCN ® Practice Guidelines in Oncology – v.2.2009 Prevention and Treatment of Cancer-Related Infections Guidelines Index Prevention/ Treatment Infection TOC Discussion, References rib ut io n ANTIVIRAL AGENTS (References are on page 4) a TREATMENT Foscarnet Prophylaxis... reserved These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN FEV-C (Page 2 of 4) NCCN ® Practice Guidelines in Oncology – v.2.2009 Prevention and Treatment of Cancer-Related Infections Guidelines Index Prevention/ Treatment Infection TOC Discussion, References AGENT rib ut io n ANTIVIRAL AGENTS (References are on page 4) TREATMENT SPECTRUM... reserved These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN FEV-8 NCCN ® Practice Guidelines in Oncology – v.2.2009 Guidelines Index Prevention/ Treatment Infection TOC Discussion, References rib ut io n FOLLOW-UP THERAPY FOR RESPONDING PATIENTS Prevention and Treatment of Cancer-Related Infections See Suggested Duration of Therapy for Documented . Oncology™ Prevention and Treatment of Cancer- Related Infections V.2.2009 www.nccn.org Practice Guidelines in Oncology – v.2.2009 Prevention and Treatment of Cancer-Related. permission of NCCN.08/28/09 Guidelines Index Prevention/ Treatment Infection TOC Discussion, References NCCN ® NCCN Prevention and Treatment of Cancer-Related Infections